Coordinated Patient Care at the Heart of Specialty Pharmacy
Patient satisfaction and coordination of care are vital to the success of a high cost specialty drug regimen.
Spending on specialty pharmaceuticals is increasing at a rate that far exceeds that of spending on traditional medications.1
This trend caused an explosion in the number of specialty pharmacies, as manufacturers and payers have implemented their utilization into marketing and cost containment strategies. From the perspective of these two major stakeholders, utilization of specialty pharmacy distribution channels creates economies of scale, and streamlines the delivery process of difficult to manage medications.2
The goal is to provide the optimization of patient care and deliver better outcomes. Services provided by specialty pharmacies go beyond regimen adherence measures, and have come to encompass disease state specific expertise, administration counseling, thermo-controlled delivery mechanisms, reimbursement navigation, and measurement of clinical and financial outcomes, to name a few.
Although these services fill the gaps in care that exist in the traditional model, specialty pharmacies are faced with some challenges in providing optimal patient care. Patient satisfaction, coordination of care, patient safety, and operational efficiency are all challenges faced by specialty pharmacies.
Overcoming these barriers begins with the referral and on-boarding process. Patients managing a serious health condition, such as cancer or HIV, are often faced with a longer and more complex process of obtaining their specialty medications compared with traditional medications.
Streamlining the process is key to mitigating patient frustration, and avoiding potential delays in the initiation of treatment. Facilitating enhanced communications between the pharmacy and the provider, as well as the pharmacy and the patient, should be at the core of the specialty pharmacy business plan.
With time-to-fill being one of the key performance indicators used to evaluate specialty pharmacy services, the referral process needs to be structured to overcome any barriers to an expedited process. Specialty pharmacies and prescribers can leverage, in many cases, referral forms supplied by manufacturers, or build their own using their clinical knowledge and experience.
Utilization of these forms can ensure receipt of the key information necessary to process a prescription, such as patient demographics, insurance information, medication history, and prescriber information. However, and perhaps more importantly, they facilitate the prescribing of complex regimens.
Electronic prescribing platforms are often restricted in their ability to handle the long sigs associated with many specialty medications. Referral forms can ease this process by providing generally accepted sigs and provide some guidance to predict issues that would trigger a potential denial to coverage.
Prior authorizations are standard utilization management strategies employed by payers seeking to control specialty expenditure. The process is complex, time-consuming, and requires multiple correspondences between the payer, the prescriber, and the pharmacy.
Pharmacies, struggle to find ways to expedite this process that is largely out of their control. However, many specialty pharmacies have developed strategies to facilitate the process for prescribing physicians.
Assembling the prior authorization packet with all of the necessary information, and returning it to the prescriber for signature and submission to the plan is one strategy; however, other pharmacies go beyond this, and serve as an agent of the prescriber. In this manner, the prescriber is completely relieved from the labor intensive process, and the specialty pharmacy, in turn, gains control over influencing turnaround time.
Ability to adopt the latter strategy depends largely on the payer’s acceptance of such practices, as well as the legal risk aversion policy of the pharmacy. Any false information provided in the prior authorization process can lead not only to termination by pharmacy benefit managers, but also criminal or civil penalties.
In fact, one specialty pharmacy in New York was fined more than $10 million for fraudulent activity associated with the prior authorization process.3
Patients, especially those with new diagnoses and, thus, new to specialty pharmacy, often find themselves confused by a model that is vastly different from the traditional pharmacy delivery model they are accustomed to. Patient engagement should be the goal, beginning with the introductory phone call.
An explanation of the specialty pharmacy delivery model can mitigate confusion, and set expectations for patients in terms of frequency and purpose of future communications, anticipated timeline of delivery, and available service offerings of the particular specialty pharmacy. The initial phone call also serves as an opportunity for the specialty pharmacy staff to enlist the aid of the individual to complete the patient medication profile.
The introduction of a specialty pharmacy into the health care team of a patient inevitably leads to the undesired consequence of increased fragmentation of care. Obtaining a complete and current drug profile and clinical picture becomes increasingly difficult in situations involving multiple pharmacies. However, by engaging the patient in a clinical assessment, the specialty pharmacy can gain a heightened level of clarity, especially when confirmed with communications from other members of the patient’s health care team.
Lastly, the on-boarding phone call should be utilized to gather information to aid in the turnaround time. Any information that could result in the delay of fulfillment if not readily available, such as insurance coverage, delivery availability, and address, should be gathered upfront or confirmed during this call.
As biotechnology has brought treatments for complex diseases into patients’ homes with the development of self-administered regimens, patients have become more accountable for their own care. Therefore, the on-boarding experience demands communications that allow the specialty pharmacy to play a pivotal role in impacting outcomes.
Patients stunned by a diagnosis, and at the mercy of a time-restricted prescriber, often fail to process or obtain all the necessary information associated with their care. A specialty pharmacy plays a pivotal role in communicating key information that will support the patient in not only receiving the treatment prescribed, but also following through with the care and maximizing its potential.
Disease and medication knowledge should be disseminated during the initial calls and on demand to the patient to eliminate any confusion, and empower the patient with knowledge.
- IMS Institute for Healthcare Informatics. Medicines Use and Spending in the U.S. A Review of 2015 and Outlook to 2020. http://www.imshealth.com/en/thought-leadership/ims-institute/reports/medicines-use-and-spending-in-the-us-a-review-of-2015-and-outlook-to-2020#form (accessed 2016 May 3).
- Schwartz R et al. NCCN Task Force Report: Specialty Pharmacy. J Natl Compr Canc Netw 2010;8:S-1-S-12.
- Levitt J and Bennet S. Specialty Pharmacy: Pitfalls when Helping Physician Offices With Prior Authoriations. http://www.frierlevitt.com/articles/pharmacylaw/specialty-pharmacy-pitfalls-when-helping-physician-offices-with-prior-authorizations/ (accessed 2016 June 22).
About the Author
Heather Brand earned her B.A. in Chemistry and PharmD from the University at Buffalo, SUNY. She worked for an oncology based pharmacy for six years prior to transitioning to a consultant role for a benefits management firm. She is currently enrolled in the Masters of Science in Pharmacy Business Administration (MSPBA) program at the University of Pittsburgh, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines.